Analysis Loading of Vessels There are no regulations governing the draught or trim to which a fishing vessel may be safely laden with fish or gear. Consequently, fishing vessels have no load lines and the loading of these vessels is left to the judgement of the operators. In this occurrence, the 160 metal lobster traps, in five tiers, weighing approximately 12 700 kg, raised the vessel's centre of gravity and contributed to reducing the vessel's freeboard to the extent that the well deck scuppers were below the waterline. Consequently, the five well deck scuppers were plugged before departure to prevent the ingress of water. Any water shipped over the gunwale would therefore be retained on board. With the scuppers plugged, a small amount of water shipped over the gunwale would give rise to the free surface effect. With a higher centre of gravity and the reduction of stability due to free surface effect, the vessel was in a vulnerable condition and unable to right itself when the successive waves came over the gunwale. In general, few fishers understand free surface effect and fewer appreciate the substantial reduction of initial transverse stability brought about when water, even a few inches deep, is shipped and retained on deck. Use of Personal Flotation Devices In this occurrence, the operator was wearing a pair of insulated coveralls, without any buoyancy features. Three of the five persons aboard were wearing full-length PFDs. The missing crew member was not wearing any flotation device. The wearing of a PFD was left to the discretion of each crew member. Full-length PFDs reduce thermal shock upon entry into cold water, delay the onset of hypothermia, provide acceptable flotation, and minimize the risk of drowning. These suits use a wetsuit principle, and the survival time of the person wearing such a suit is not as high as that afforded by drysuits, i.e. immersion suits. Standard lifejackets, unlike PFDs, must meet rigid buoyancy standards and have the ability to turn an unconscious person to a face-up position in the water, but they provide poor thermal protection in the cold water. There are several types of commercially available full-length outer workwear that provide buoyancy and afford protection from the effects of cold water immersion. In the past, fishers have been reluctant to wear this type of outer workwear because they consider it to be restrictive and difficult to wear while working. Improvements have been made to the design and manufacture of this type of outer workwear, and its use is gaining acceptance within the fishing industry. Quick Release Devices on Liferaft Lashings In this instance, the liferaft on the JOSEPH SISTERS was secured with rope lashings but did not have a quick release device. The vessel carried an inflatable liferaft on board although it was not required by regulation. The regulations require certain fishing vessels to carry a liferaft; however, regulations do not describe how the liferaft is to be secured to the vessel. TC has published a handbook providing information on safety on small fishing vessels for operators who do not hold a certificate of competency.[5] The Manual states that an inflatable liferaft should be secured with a senhouse slip and weak link or a hydrostatic release. On small fishing vessels, some operators fear that liferafts could be dislodged from their stowed position if not well secured or if fitted with a hydrostatic release device. For this reason, they may use additional rope lashings to secure the liferafts. However, liferafts need to be launched in emergency situations, and it is imperative that any securing arrangements be such that the liferaft can be launched quickly and safely. While the liferaft on board the JOSEPH SISTERS was approved for four persons, there were five crew members on board the vessel. The operator of the JOSEPH SISTERS encountered the adverse weather that was forecast by Environment Canada. The vessel shipped water over the gunwale. The free surface effect created by the water entrapped on the well deck caused its list and contributed to reducing the vessel's stability. The operator had not listened to the weather forecast issued by Environment Canada prior to his departure from Delhaven. He relied on his knowledge and on a weather-related broadcast from a local radio station, and was unaware of impending adverse weather. The JOSEPH SISTERS loaded onto its well deck 160 metal lobster traps five tiers high, weighing about 12 700 kg (28 000 lbs), to a height of approximately 2 m (6 ft). The weight of the lobster traps raised the vessel's centre of gravity, thereby reducing the vessel's stability. This was the third season in which the vessel had been loaded with 160 lobster traps for the first day of the fishing season. The operator put in the scupper plugs to prevent the ingress of water from the vessel's scuppers, which would be under the waterline when the lobster traps were loaded on board. The missing crew member was the only one not wearing a PFD. Because the lifejackets were kept in the cuddy, he may not have had time to avail himself of a lifejacket after the first wave hit the vessel. The vessel had been inspected by TC. A certificate was issued based on a crew of three persons, including the operator. Consequently, the life-saving equipment included a four-person inflatable liferaft, three lifejackets, and one lifebuoy. At the time of its sinking, the vessel had a crew of five. The inflatable liferaft was lashed with rope and was not equipped with a quick release device. Canadian regulations do not require the operators or crews of small fishing vessels of 60 GT or less to hold a marine certificate of competency or to undergo marine safety-related training. Neither the operator nor the crew had any formal marine safety-related training, vessel stability training, or certificates of competency. None of the crew were given instructions in the use of life-saving equipment.Findings The operator of the JOSEPH SISTERS encountered the adverse weather that was forecast by Environment Canada. The vessel shipped water over the gunwale. The free surface effect created by the water entrapped on the well deck caused its list and contributed to reducing the vessel's stability. The operator had not listened to the weather forecast issued by Environment Canada prior to his departure from Delhaven. He relied on his knowledge and on a weather-related broadcast from a local radio station, and was unaware of impending adverse weather. The JOSEPH SISTERS loaded onto its well deck 160 metal lobster traps five tiers high, weighing about 12 700 kg (28 000 lbs), to a height of approximately 2 m (6 ft). The weight of the lobster traps raised the vessel's centre of gravity, thereby reducing the vessel's stability. This was the third season in which the vessel had been loaded with 160 lobster traps for the first day of the fishing season. The operator put in the scupper plugs to prevent the ingress of water from the vessel's scuppers, which would be under the waterline when the lobster traps were loaded on board. The missing crew member was the only one not wearing a PFD. Because the lifejackets were kept in the cuddy, he may not have had time to avail himself of a lifejacket after the first wave hit the vessel. The vessel had been inspected by TC. A certificate was issued based on a crew of three persons, including the operator. Consequently, the life-saving equipment included a four-person inflatable liferaft, three lifejackets, and one lifebuoy. At the time of its sinking, the vessel had a crew of five. The inflatable liferaft was lashed with rope and was not equipped with a quick release device. Canadian regulations do not require the operators or crews of small fishing vessels of 60 GT or less to hold a marine certificate of competency or to undergo marine safety-related training. Neither the operator nor the crew had any formal marine safety-related training, vessel stability training, or certificates of competency. None of the crew were given instructions in the use of life-saving equipment. The JOSEPH SISTERS capsized and sank because the vessel was overloaded with 160 metal lobster traps that, stacked 2 m high on deck, reduced the static stability of the vessel. When the vessel encountered adverse weather at sea, three successive waves shipped water onto the well deck, causing a free surface effect that further reduced its stability, and it capsized. The vessel then partially righted in a flooded condition and sank stern first. There are no provisions requiring an operator of a small fishing vessel (of 60 GT or less) to have marine safety-related training. None of the crew had been instructed in the use of life-saving equipment, and the missing crew member was not wearing a PFD.Causes and Contributing Factors The JOSEPH SISTERS capsized and sank because the vessel was overloaded with 160 metal lobster traps that, stacked 2 m high on deck, reduced the static stability of the vessel. When the vessel encountered adverse weather at sea, three successive waves shipped water onto the well deck, causing a free surface effect that further reduced its stability, and it capsized. The vessel then partially righted in a flooded condition and sank stern first. There are no provisions requiring an operator of a small fishing vessel (of 60 GT or less) to have marine safety-related training. None of the crew had been instructed in the use of life-saving equipment, and the missing crew member was not wearing a PFD. Safety Action Action Taken In December 1998 the Small Fishing Vessel Safety Working Group was established by Transport Canada, Marine Safety (TCMS), to review the 1993 draft Small Fishing Vessel Safety Regulations. Subsequent to this occurrence, the TSB forwarded a Marine Safety Information Letter (No. 02/00) to TCMS. The letter indicated that TCMS may wish to ensure that deficiencies associated with survival techniques and unsafe operating practices on board fishing vessels are adequately addressed by the Working Group. With respect to survival techniques, Section 21 of the Crewing Regulations was Amended to state that, beginning on 30 July 2002, all fishers, certificated or not, must have completed a minimum of basic MED training (A1) before having completed six months' service, and must obtain a certificate of the crew member's successful completion of basic safety training (A1). On the subject of unsafe operating practices/crew certification, TCMS noted that, at present, the regulations do not require a fishing vessel under 60 GT to have a certificated master. However, TCMS, in its National Discussion Paper, has indicated that it will require all masters/operators of craft/vessels under TC jurisdiction to have a qualification recognized by TCMS. At present, TCMS is considering extending a modified certificate of service course to all fishers, regardless of the tonnage of their vessels. To date this proposal has been met positively by the fishing industry.